Parents Instruct Irwin Mitchell after Staff ‘Missed Opportunities’ To Raise Concerns with Senior Colleagues

Hospital staff missed three chances to escalate concerns over the health of a baby boy who was delivered stillborn after a mum, whose waters had broken was sent home, an investigation has found.

Sherwood Forest Hospitals NHS Foundation Trust has conducted a serious incident investigation report following the death of baby Freddie Webster at King’s Mill Hospital in Sutton-in-Ashfield, Nottinghamshire.

The investigation identified a number of “care and delivery problems”. NHS bosses have drawn up an action plan drawn in a bid to stop further incidents.

Following baby Freddie’s death, his parents, Kayleigh Turton, aged 26, and Scott Webster, aged 29, from Sutton-in-Ashfield, Mansfield, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the level of care Kayleigh received at the hands of the NHS trust.

Expert Opinion

The serious incident investigation report highlights a number of criticisms in the care Kayleigh received, in particularly that her and her baby’s condition should have been escalated to a Consultant on a number of occasions throughout her labour. However, no attempts were ever made to contact such a Consultant.

“Kayleigh and Scott have understandably been left devastated by the loss of baby Freddie. While nothing can ever make up for their loss, the couple hope that by admitting its mistakes, Sherwood Forest Hospitals NHS Foundation Trust will learn from this tragic case so no parents have to experience the suffering they have had to go through.

"It is very important for Kayleigh and Scott that they are able to raise awareness of their tragic loss so serious lessons can be learnt.” Laura Hopkinson - Solicitor

Kayleigh, who was 41+5 weeks pregnant, was due to be induced at 2pm on 10 June 2017. Kayleigh had not had an easy pregnancy and had already been admitted twice to hospital with hyperemesis gravidarum (a very severe form of morning sickness).

On the day that Kayleigh was due to be induced she attended King’s Mill Hospital after her waters broke on the morning of 10 June. She was sent home after routine tests were undertaken.

However, she was admitted at 6.05pm showing signs of sepsis. She was examined by a registrar and a plan for her labour initiated with regular observations carried out.

At 2am the next day tests showed baby Freddie’s heart rate was slowing down and not normal. The CTG monitoring remained suspicious thereafter. It is understood that at 03:36 the monitoring of baby Freddie’s heart was difficult to interpret. At 5.45am tests highlighted further serious concerns about his heart rate and the fact that it was very slow. An emergency caesarean was ultimately performed but baby Freddie was born showing no signs of life and could not be resuscitated.    

The report found the following:

• The hospital failed to follow National Institute for Health Care and Excellence sepsis guidelines and advise Kayleigh how ill she was and that her baby’s life was in danger.
• Staff missed three chances to raise concerns about baby Freddie’s condition to a consultant who was on-call and should have been informed.  These included when Kayleigh was admitted with sepsis at 6.05pm and at 2am when baby Freddie’s heart rate started to show signs of distress. Unfortunately, this was when the registrar was in theatre with another patient and again at 2.45am when the registrar was still in theatre.
• A busy ward impacted on the care Kayleigh received and the swift administering of antibiotics to treat her sepsis.
• Hospital staff struggled to contact a paediatrician to try and resuscitate baby Freddie because consultants had swapped shifts and not informed switchboard operators.  When a less qualified registrar did arrive she did not feel supported by her more senior colleagues.
• The hospital has accepted that there were potential opportunities to deliver baby Freddie earlier.

Concerns have also been raised that some of the phone calls which Kayleigh and Scott made to the hospital on June 10 with fears for her condition were not logged.

The serious incident investigation has made 12 recommendations including training staff on managing labour where a mum has suspected sepsis, escalating concerns about a baby’s condition is now essential, consultants to be fully informed of obstetric cases and consultants should personally inform switchboard operators about rota changes.

Kayleigh said: “As an expectant mother you have faith in those treating you - they are the professionals – but I was scared and did not feel my concerns were listened to.

“The pain of losing Freddie is indescribable and I’m not sure we’ll ever really come to terms with it.

“Nothing could bring Freddie back or begin to make up for what happened but the hospital trust now needs to make sure it enforces the recommendations highlighted in the report to ensure nobody else has to suffer the feelings of anger, pain and loss we have.”

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